1. AIR INDIA and CRM March 2011

5. The captain (55, Serbian, ATPL, 10,215 hours as pilot in command, 2,844 hours on type) was described by collegues as a friendly person and ready to help the first officers with professional information. He was "assertive" and tended to indicate he was always right. The first officer (40, Indian, ATPL, 3,620 hours total flying experience, 3,319 on type) was known as a man of few words and meticulous in his adherence to standard operating procedures. He had filed a complaint about another of the foreign captains, the company had therefore instructed rostering personnel to not pair the two before counseling had taken place (which did not occur before the crash). Air India Express had mandated that due to the table top runway takeoffs and landings in Mangalore had to be flown by the captain. The crew had performed the outbound flight IX-811 to Dubai and was to conduct flight IX-812 back to Mangalore. Ground personnel in Dubai reported that both crew appeared normal and healthy. They had left the aircraft and gone to the terminal building and the duty free shop during their 82 minutes turn over in Dubai. The crew did perform all pre-departure checks according to observations by ground personnel. The flight was to depart at 01:15 local Dubai time (21:15Z), which is 02:45 local Mangalore time and was estimated to arrive at 06:30 local Mangalore time (01:00Z).

6. Data off the flight data recorder and ATC recordings show the departure, climb and cruise of the aircraft were uneventful. The cockpit voice recorder featured a capacity of 125 minutes. During the first 100 minutes of the recording there was no communication between the pilots however, all radio communication was done by the first officer. The captain's microphone occasionally recorded sounds consistent with deep breathing and mild snoring, at the later stages sounds of clearing the throat and coughing. The first officer reported to Mangalore Area Control Center while overflying waypoint IGAMA at FL370 and requested radar identification at which time he was told that Mangalore's radar was out of service (starting May 20th 2010). About 5 minutes later, about 130nm before Mangalore, the first officer requested the type of approach to expect, was told to expect the ILS DME Arc approach to runway 24, and requested descent. ATC denied the descent however due to procedural control available only and instructed IX-812 to report at 80 DME on radial 287 of Mangalore's VOR MML. About 9 minutes after reporting over IGAMA - and about 25 minutes before the overrun of the runway - the first verbal communication ("What?") by the captain was captured by the captain's microphone. About 13 minutes after overflying IGAMA the first officer reported 80 DME on radial 287 and was cleared to 7000 feet , the descent commenced at 77nm from Mangalore VOR .

7. While the aircraft descended through FL295 an incomplete approach briefing was carried out, no standard approach briefing was conducted. At some stage during the descent, the actual time not mentioned in the report, the speed brake handle was placed in the flight detent and speed brakes deployed accordingly. About 25nm before Mangalore the airplane was descending through FL184, still substantially above the descent profile, when the air traffic controller cleared the aircraft to 2900 feet. The aircraft was subsequently handed to Mangalore Tower, who requested the crew to report once established on the 10 DME Arc. At about that time yawning was recorded by the first officer's microphone. After the crew reported established on the Arc ATC requested to report when established on the ILS. At that time it is obvious the captain realised the airplane was too high on the approach. He had the gear lowered while descending through 8500 feet, speed brakes were still extended. The aircraft continued to be high, intercepted the localizer beam and captured the false glideslope beam at double the correct approach angle (6 instead of 3 degrees descent). There was no cross check between actual altitudes/heights with the descent profile provided in the approach chart conducted by the crew.

8. Flaps were extended to 40 degrees, speed brakes were still extended. On final approach, about 2.5nm from touch down, the radar altimeter went through 2500 feet, the first officer reacted to the aural message with "It is too high" and "runway straight down", the captain responded "Oh my God". The captain disconnected the autopilot and increased the rate of descent reaching about 4000 feet per minute sink rate. The first officer asked "Go Around?", to which the captain responded "wrong loc ... localizer ... glide path". The CoI analysed that this was indicative of the captain recognizing the error and not being incapacitated due to his subsequent actions to correct the error. The speed brakes were stowed and armed. The first officer called a second "Go Around! Unstabilized!", however , the first officer did not take any further action to initiate a go-around, although company procedures required the first officer to take control after a second call to go around not complied with by the captain. The captain further increased the rate of descent, the speed brakes were extended again until 20 seconds before touch down. Numerous EGPWS aural warnings ("Sink Rate!" "Pull Up!") were issued in this phase of the approach.

9. The airplane crossed the runway threshold at 200 feet AGL at a speed of 160 KIAS instead of the target 50 feet AGL at 144 KIAS and touched down about 4500 feet down the runway, bounced and touched down a second time 5200 feet down the runway with just 2800 feet of paved surface remaining. Soon after touchdown the captain selected reverse thrust, autobrakes set to level 2 operated. About 6 seconds after the brakes began operating and after the reversers were selected the captain announced "Go Around" - against Boeing standard operating procedures not permitting go-arounds after selecting reverse thrust -, the brakes pressure decreased, the thrust reversers returned to their stowed position, both thrust levers were moved fully forward, the speed brakes retracted and remained retracted, the engines accelerated to 77.5/87.5% N1. The airplane departed the paved surface, the right wing impacted the localizer antenna, the aircraft went through the airport perimeter fence, fell down a gorge, broke up in three major parts and burst into flames. No distress call was received at any time. All but 8 passengers aboard perished. The survivors, while getting up from their seats, heard and saw a number of other passengers unbuckle their seat belts, but they could not move due to the rapid spread of fire. All survivors escaped through cracks of the fuselage. 7 survivors received serious injuries, one escaped with minor injuries. Boeing later determined that if the crew had applied maximum manual braking after second touch down, the airplane would have stopped 7600 feet past the runway threshold meaning the aircraft would have stopped within the paved surface of the runway (8033 feet long).

10. Unstablised Approach No briefing No standard Call-outs or deviation calls Omit check list High & fast Decide to land Runway Over run Forget flaps Late descent A HIGH RISK APPROACH High workload Poor planning

11. AVIATION HAS MANY SAFETY MECHANISMS WHICH MAY CONTAIN CERTAIN GAPS

12. THESE GAPS ARE CALLED THREATS, AND ARE TRAPPED BY HAVING MULTIPLE LEVELS OF SAFETY MECHANISMS

13. ACCIDENTS OCCUR WHEN ALL THE GAPS IN THE DEFENCE MECHANISMS LINE UP : THE CREW IS THE LAST LINE OF DEFENCE

19. CAPT – What do you say ? F/O – Yup ! F/E – Is he not clear that Pan Am CAPT – Oh yes! F/O - Oh yes! [Pan Am] B-747 Pan American CAPT – Let’s get the hell out of here ! F/O – Yeh, he’s anxious isn’t he. F/E – Yeh, after he held us up for an hour & a half.. Now he’s in a rush CAPT – There he is ..look at him Goddamn .. That son-of-a-bitch is coming ! Get off Get off ! Get off ! Ground collision between two 747’s after KLM crew took off without clearance. 583 Die as Jumbos hit

24. Extract of the Court of Inquiry Report: The captain (2,844 hours on type) was described by colleagues as a friendly person and ready to help the first officers with professional information. He was "assertive" and tended to indicate he was always right. The first officer (40, Indian, ATPL, 3,620 hours total flying experience, 3,319 on type) was known as a man of few words and meticulous in his adherence to standard operating procedures.

25. CRM AT AN INDIVIDUAL LEVEL

26. CRM AT AN INDIVIDUAL LEVEL Personality trait Positive trait Negative Trait (Teamwork breaks down) Child Happy and free (leads to good teamwork) Reacts emotionally to situations Parent: Nurtures people (leads to good teamwork) Can become too critical: Adult Unemotional focus on meeting the challenges of the situation (gets work done) Can appear too aloof

27. Desirable: Happy Free child/nurturing parent when interacting with crew : Rational Unemotional Adult when dealing with work situations WHAT IS YOUR PERSONALITY LIKE? Un-desirable: Angry/unhappy child/critical parent when interacting with crew or dealing with work situations CRM AT AN INDIVIDUAL LEVEL

31. Pilots can avoid accidents by controlling their hazardous attitudes CRM AT AN INDIVIDUAL LEVEL

32. Extract of the Court of Inquiry Report: : Ground personnel in Dubai reported that both crew appeared normal and healthy. They had left the aircraft and gone to the terminal building and the duty free shop during their 82 minutes turn over in Dubai. The crew did perform all pre-departure checks according to observations by ground personnel. • synergy • authority vs leadership • assertiveness • barriers • cultural influence • roles- leader/follower • credibility • team responsibility CRM AT A TEAM LEVEL

33. 1+1 is more than 2 Synergy means increased effectiveness of two individuals when they work as a team CRM AT A TEAM LEVEL

34. Some conditions for synergy cogs turning & interconnecting smoothly: requires Good communication & decision making a leader a shared objective a correct task allocation  Objective Task Leader Atmosphere 1+1 is more than 2 CRM AT A TEAM LEVEL Was there synergy in the IX 812 cockpit? “ During the first 100 minutes of the recording there was no communication between the pilots however, all radio communication was done by the first officer….”

35. • what will I - he/she/ the machine do next ? • what can happen to us ? • what should I - he/she monitor ? A shared plan for action Objective Task Leader Atmosphere 1+1 is more than 2 CRM AT A TEAM LEVEL Was there a shared plan of action in the IX812 cockpit?: “ While the aircraft descended through FL295 an incomplete approach briefing was carried out, no standard approach briefing was conducted…”

42. In the end… it is the attention to detail that makes the difference It is the thing that separates the winners from the losers, the men from the boys, and very often the living from the dead.

45. CRM AT A TEAM LEVEL In the IX 812 cockpit, was the first officer assertive enough?.. “ Probably in view of ambiguity in various instructions empowering the ‘copilot’ to initiate a ‘go around’, the First Officer gave repeated calls to this effect, but did not take over the controls to actually discontinue the ill-fated approach .

48. CRM AT A TEAM LEVEL Power distance refers to the degree of democracy in human relationships. In a high power-distance culture (e.g., India, Malaysia, & Philippines), leaders are more likely to be expected to be decisive, and subordinates are expected to be more submissive . In countries with lowerpower distance, such as the United Kingdom, Australia and Denmark, subordinates feel more comfortable about approaching superiors and, if necessary, contradicting them . Medium Power Distance is considered to be desirable in multi-crew cockpits

49. Individualism vs. Collectivism: Individualistic societies, such as the United Kingdom, United States and Australia, emphasize personal initiative and individual achievement. Collectivist societies, such as India, Brazil, Taiwan and Korea, emphasize the importance of group membership and cohesiveness of the group over individual achievement. In collectivist societies, there is a tendency to avoid open conflicts. A first officer from a collectivist society would be less likely to challenge a captain who is doing something that the first officer feels uncomfortable with. CRM AT A TEAM LEVEL

50. POWER DISTANCE I N D I V I D U A L I S M India Japan Greece Korea Indonesia Malaysia Spain USA Austria Sweden Costa Rica Australia DANGER ZONE With high collectivism and high power distance the result is that a person with higher authority is not to be challenged, even if there is something that does not seem right, as it is deemed to be outside accepted cultural behaviour . 1+1 is less than 2 CRM AT A TEAM LEVEL

51. The ethnical theory about aircraft accidents is due to two aircraft accidents (Colombian Avianca Flight 52 and South Korean Air Flight 801) Flight 801 departed from Seoul-Kimpo International Airport at 8:53 pm (9:53 pm Guam time) on August 5, 1984 on its way to Guam. It carried 2 pilots, 1 flight engineer, 14 flight attendants, and 237 passengers, There was heavy rain at Guam so visibility was significantly reduced and the crew was attempting an instrument landing. Air traffic control in Guam advised the crew that the glideslope Instrument Landing System (ILS) in runway 6L was out of service. Air traffic control cleared Flight 801 to land on runway 6L at around 1:40 am. The crew noticed that the plane was descending very steeply, and noted several times that the airport "is not in sight". At 1:42 am, the aircraft crashed into Nimitz Hill, about 3 nautical miles (5 km) short of the runway, at an altitude of 660 feet (201 m). The NTSB Report said ‘..The captain also failed to follow a normal non-precision approach and prematurely descended to impact a hillside short of the runway. Contributing to the accident were the captain's fatigue, Korean Air's lack of flight crew training, as well as the intentional outage of the Guam ILS Glideslope due to maintenance. The crew had been using an outdated flight map, which stated that the Minimum Safe Altitude for a landing plane was 1,770 feet (540 m) as opposed to 2,150 feet (656 m). Flight 801 had been maintaining 1,870 feet (570 m) when it was waiting to land ’

53. Mangalore effect: DGCA emphasizes role of co-pilot in a crisis TNN, Aug 11, 2010, 03.52am IST MUMBAI: If the commander of a flight doesn't respond to a situation, which demands that the aircraft should discontinue its descent for landing and pull up and do a go-around, then the first officer should take over the controls and do the needful. There is nothing new in this norm, as it is already a standard operating procedure in airlines. What is new is that the Directorate-General of Civil Aviation ( DGCA) on Tuesday issued an operations circular to stress once again the particular role that a first officer needed to follow in such a situation. Although the circular doesn't say it, it's apparent that this is one of the factors that led to the May 22 Mangalore air crash. The co-pilot called for a go-around but the commander ignored it and the co-pilot didn't take over the controls and the Boeing 737 eventually crashed. CRM AT A TEAM LEVEL

54. CRM AT A TEAM LEVEL

55. 2 ! UNSTABILISED GO AROUND!!! CRM AT A TEAM LEVEL

56. CONFLICT MANAGEMENT  You all agree with me, don’t you?!! CRM AT A TEAM LEVEL i

62. GO AROUND! CRM AT A TEAM LEVEL

67. Listen Active Listening Tips Do not listen in parallel with performing concurrent tasks. Stop what you are doing, listen, and then resume. Always use standard phraseology. Read-back ATC instructions and listen out for any ATC corrections If in doubt - CROSS CHECK. If, even after a correct read-back, you feel that there is an ambiguity in the clearance, ask again Query unclear or incomplete transmissions, especially if you suspect they may have been blocked. CRM AT A TEAM LEVEL Sender (transmission)

70. CRM AT A TEAM LEVEL Fatigue: The cockpit voice recorder featured a capacity of 125 minutes. During the first 100 minutes of the recording there was no communication between the pilots however, all radio communication was done by the first officer. The captain's microphone occasionally recorded sounds consistent with deep breathing and mild snoring, at the later stages sounds of clearing the throat and coughing. Poor Workload management: While the aircraft descended through FL295 an incomplete approach briefing was carried out, no standard approach briefing was conducted Unprofessionalism: The aircraft continued to be high, intercepted the localizer beam and captured the false glideslope beam at double the correct approach angle (6 instead of 3 degrees descent). There was no cross check between actual altitudes/heights with the descent profile provided in the approach chart conducted by the crew

73. OPERAT-IONAL LEVEL CRM

82. Bad enough on the ground…but in the air???

85. When performance drops due fatigue or stress consider using 1. Optimum levels of automation 2. Handing over controls 3. Additional crew members for flight watch

87. 7- A THREAT & ERROR MANAGEMENT MODEL

89. Was there any external threat in the IX 812 accident? The first officer reported to Mangalore Area Control Center while overflying waypoint IGAMA at FL370 and requested radar identification at which time he was told that Mangalore's radar was out of service (starting May 20th 2010 ). About 5 minutes later, about 130nm before Mangalore, the first officer requested the type of approach to expect, was told to expect the ILS DME Arc approach to runway 24, and requested descent. ATC denied the descent however due to procedural control available only TYPE Industry Average-4.2 /flight Environmental ( 43% in descent/ Aproach & Land Phases) Adverse Weather (25%) Thunderstorms, Turbulence, Poor Visibility, Wind Shear, Icing Airport (7%) Poor Signage, Faint Markings, Runway/Taxiway Closures, Inop Navaids , Poor Braking action, Contaminated Runway/Taxiways ATC (25%) Difficult to follow/changing clearances and restrictions* , re-routes, language difficulties, Controller Errors (*most problematic threat) Operational Pressures Terrain, Traffic, TCAS TA/RA, Radio Congestion Airline ( 73% in Pre-Departure/Taxi-out Phases) Aircraft (13%) System Malfunctions, MEL with Operational Procedures Operational Pressure On Time Performance Pressure, Delays, Late arrival Aircraft/Aircrew Cabin Cabin Events and Cabin Crew Errors, Distractions and Interruptions. Despatch / paperwork Crew Scheduling events, Delayed or Erroneous Flight Plans and Other Documents, Load and Trim Errors Ground/ Ramp Aircraft Loading Events, Fuelling Errors, Commercial Staff Interruptions, Improper Ground Support, De-icing Maintenance Aircraft Repairs on ground, Aircraft Log problems, Maintenance errors Manuals and Charts Missing Information or Document Errors.

92. ERRORS & THEIR CONSEQUENCES

94. Was there any crew errors in the IX 812 accident? Numerous EGPWS warnings ("Sink Rate!" "Pull Up!") were issued The aircraft continued to be high, intercepted the localizer beam and captured the false glideslope beam at double the correct approach angle ..There was no cross check between actual altitudes/heights with the descent profile …by the crew an incomplete approach briefing was carried out, no standard approach briefing was conducted About 6 seconds after the brakes began operating and after the reversers were selected the captain announced "Go Around" - against Boeing standard operating procedures not permitting go-arounds after selecting reverse thrust -, TYPE Industry Average-4.2 /flight AIRCRAFT HAND -LING Automation Incorrect autothrottle, speed, altitude and heading settings, mode selection or entries Flight Control Incorrect thrust, thrust reverser, flaps/slats, speed-brakes , auto-brakes, anti-skid, parking brake and trim settings Gnd Navigation Attempting to proceed on wrong taxi-way/runway . Missed taxiway/runway/gate. Manual Flying Hand-flying vertical, lateral or speed deviations. Missed taxiway or runway hold short clearance(runway incursion) , or taxi above speed limit. Systems, Radio, Instruments Incorrect Pack, altimeter, radio or fuel switch setting. PROCE-DURAL Briefings Missed items in briefing- omitted Departure, Takeoff, Approach or Handover briefing Callouts Omitted takeoff, descent or approach callouts Checklist Performed checklist from memory or omitted a checklist Documentation Wrong Weight and Balance, fuel information, ATIS or clearance recorded. Misinterpreted items on paperwork. PF/PNF duty PF makes own automation changes, PNF doing PF duty, PF doing PNF duty SOP Cross-Verification Intentional and unintentional failure to cross-verify automation inputs Other Procedural Other deviations from government regulations, flight manual requirements or SOP COMM-UNICA-TION Crew to External Missed Calls, misinterpretation of instructions or incorrect read-backs to ATC, Wrong Clearance, Taxiway, gate or runway communicated Pilot to Pilot Within crew miscommunication or misinterpretation

95. UNDESIRED AIRCRAFT STATES Undesired aircraft states are defined as ‘flight crew-induced aircraft position or speed deviations, misapplication of flight controls, or incorrect systems configuration,

96. UNDESIRED AIRCRAFT STATE (REDUCED SAFETY MARGINS ) MISMANAGED INCIDENT/ACCIDENT UN-ANTICIPATED, MISMANAGED THREATS UNDETECTED ERRORS- THRUST, SPEED, ALTITUDE ,DIRECTION AND CONFIGURATION, PROCEDURAL, COMMUNICATION HAZARDOUS ATTITUDES A NTI- AUTHORITY, IMPULSIVITY, INVULNER-ABILITY,MACHISMO ,COMPLACENCY RESIGNATION SYSTEM MALFU-NCTION TURBULENCE, WIND SHEAR ,ICING POOR VISIBILITY ATC ERRORS LANGUAGE DIFFICULTIES CHANGED/ DIFFICULT CLEARANCES GROUND/CABIN DISTRACTIONS/ CREW ERRORS POOR SIGNAGE,FAINT MARKINGS, RUNWAY/TAXIWAY CLOSURE/,INOP NAVAIDS/POOR BRAKING ACTION / CONTAMINATED RUNWAY/TAXIWAY TERRAIN

97. Undesired aircraft state Incident / Accident

101. Culture Behaviour Followership Communication Leadership Pillars of Teamwork Resource Management & Decision Making Attitudes & Discipline Personality and Turnout Task sharing ,Time & Workload Management Automation Threat and Error Management Stress Management Knowledge and Flying Proficiency CRM is a Tool for reducing Incidents & Accidents Situational Awareness and Control

103. A CASE STUDY 15 YEARS BEFORE THE MANGALORE CRASH, A SIMILAR INCIDENT TOOK PLACE..

110. CREDITS: OPERATIONS TRAINING DIVISION, MUMBAI AIR INDIA LTD. MARCH 2011